Waukesha County Choice Plus Retiree Health Plan with ...€¦ · 01/01/2018 · Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, Utah 84130-0555;

Waukesha County Choice Plus Retiree Health Plan with Prescription Drug Effective: January 1, 2018 Group Number: 704483

Summary Plan Description

WAUKESHA COUNTY MEDICAL CHOICE PLUS RETIREE HEALTH PLAN

I TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 - WELCOME ................................................................................................................. 1

SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3

Cost of Coverage ......................................................................................................................... 3

How to Enroll .............................................................................................................................. 4

When Coverage Begins ............................................................................................................... 4

Changing Your Coverage ............................................................................................................ 4

SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7 Accessing Network and Non-Network Benefits .................................................................... 7

Eligible Expenses ......................................................................................................................... 9

Annual Deductible ..................................................................................................................... 10

Coinsurance ................................................................................................................................ 10

Out-of-Pocket Maximum ......................................................................................................... 11

SECTION 4 - PERSONAL HEALTH SUPPORT ............................................................................ 12 Prior Authorization.................................................................................................................... 13

Covered Health Services which Require Prior Authorization ............................................. 13

Special Note Regarding Medicare ............................................................................................ 14

SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 15

SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 23 Ambulance Services - Emergency only .................................................................................. 23

Autism Spectrum Disorder Services ....................................................................................... 23

Cancer Resource Services (CRS) ............................................................................................. 26

Congenital Heart Disease (CHD) Surgeries ........................................................................... 26

Dental Services - Accident Only .............................................................................................. 27

Diabetes Treatment ................................................................................................................... 28

Durable Medical Equipment (DME) ...................................................................................... 28

Emergency Health Services - Outpatient ............................................................................... 29

Eye Examinations ...................................................................................................................... 30

Foot Care .................................................................................................................................... 30


II TABLE OF CONTENTS

Hearing Aids ............................................................................................................................... 30

Home Health Care ..................................................................................................................... 30

Hospice Care .............................................................................................................................. 31

Hospital - Inpatient Stay ........................................................................................................... 32

Infertility Services ...................................................................................................................... 32

Injections received in a Physician's Office ............................................................................. 32

Kidney Disease Treatment ....................................................................................................... 32

Kidney Resource Services (KRS) ............................................................................................. 33

Maternity Services ...................................................................................................................... 33

Mental Health Services .............................................................................................................. 34

Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 35

Ostomy Supplies ........................................................................................................................ 36

Outpatient Surgery, Diagnostic and Therapeutic Services .................................................. 37

Physician Fees for Surgical and Medical Services ................................................................. 38

Physician's Office Services - Sickness and Injury .................................................................. 38

Preventive Care Services ........................................................................................................... 38

Prosthetic Devices ..................................................................................................................... 39

Reconstructive Procedures ....................................................................................................... 40

Rehabilitation Services - Outpatient Therapy ........................................................................ 41

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 43

Spinal Treatment ........................................................................................................................ 43

Substance Use Disorder Services ............................................................................................ 43

Temporomandibular Joint (TMJ) Services ............................................................................. 44

Transitional Care Services for Mental Health Services and Substance Use Disorder ..... 45

Transplantation Services ........................................................................................................... 46

Travel and Lodging .................................................................................................................... 47

Urgent Care Center Services .................................................................................................... 49

Wisdom Teeth Services ............................................................................................................. 49

SECTION 7 - CLINICAL PROGRAMS AND RESOURCESRESOURCES .................................... 50 Consumer Solutions and Self-Service Tools .......................................................................... 50

Disease and Condition Management Services ....................................................................... 53

Wellness Programs ..................................................................................................................... 55


III TABLE OF CONTENTS

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER .......................... 56 Alternative Treatments .............................................................................................................. 56

Autism Spectrum Disorder ....................................................................................................... 56

Comfort or Convenience .......................................................................................................... 57

Dental .......................................................................................................................................... 57

Drugs ........................................................................................................................................... 58

Experimental or Investigational Services or Unproven Services ........................................ 59

Foot Care .................................................................................................................................... 59

Medical Supplies and Appliances ............................................................................................. 59

Mental Health/Substance Use Disorder ................................................................................ 60

Nutrition ...................................................................................................................................... 61

Physical Appearance .................................................................................................................. 61

Providers ..................................................................................................................................... 62

Reproduction .............................................................................................................................. 62

Services Provided under Another Plan ................................................................................... 62

Transplants .................................................................................................................................. 63

Travel ........................................................................................................................................... 63

Vision ........................................................................................................................................... 63

All Other Exclusions ................................................................................................................. 63

SECTION 9 - CLAIMS PROCEDURES .......................................................................................... 66 Network Benefits ....................................................................................................................... 66

Non-Network Benefits ............................................................................................................. 66

Prescription Drug Benefit Claims ........................................................................................... 66

If Your Provider Does Not File Your Claim......................................................................... 66

Health Statements ...................................................................................................................... 68

Explanation of Benefits (EOB) ............................................................................................... 68

Claim Denials and Appeals ....................................................................................................... 68

Federal External Review Program ........................................................................................... 70

Limitation of Action .................................................................................................................. 76

SECTION 10 - COORDINATION OF BENEFITS (COB) ................................................................ 77 Determining Which Plan is Primary ....................................................................................... 77

When This Plan is Secondary ................................................................................................... 78


IV TABLE OF CONTENTS

When a Covered Person Qualifies for Medicare ................................................................... 79

Right to Receive and Release Needed Information .............................................................. 80

Overpayment and Underpayment of Benefits ....................................................................... 80

SECTION 11 - SUBROGATION AND REIMBURSEMENT ............................................................ 82 Right of Recovery ...................................................................................................................... 85

SECTION 12 - WHEN COVERAGE ENDS ..................................................................................... 87 Coverage for a Disabled Child ................................................................................................. 88

Continuing Coverage Through COBRA ................................................................................ 88

When COBRA Ends ................................................................................................................. 92

SECTION 13 - OTHER IMPORTANT INFORMATION ................................................................... 94 Qualified Medical Child Support Orders (QMCSOs) .......................................................... 94

Your Relationship with UnitedHealthcare and Waukesha County .................................... 94

Relationship with Providers ..................................................................................................... 95

Your Relationship with Providers ........................................................................................... 95

Interpretation of Benefits ......................................................................................................... 96

Information and Records .......................................................................................................... 96

Incentives to Providers ............................................................................................................. 97

Incentives to You ....................................................................................................................... 97

Rebates and Other Payments ................................................................................................... 98

Workers' Compensation Not Affected ................................................................................... 98

Future of the Plan ...................................................................................................................... 98

Plan Document .......................................................................................................................... 98

Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement Policies ......................................................................................................................................... 98

SECTION 14 - GLOSSARY .......................................................................................................... 100

SECTION 15 - PRESCRIPTION DRUGS ..................................................................................... 112 Prescription Drug Coverage Highlights ............................................................................... 112

Identification Card (ID Card) – Network Pharmacy .......................................................... 113

Benefit Levels ........................................................................................................................... 113

Retail .......................................................................................................................................... 114

Mail Order ................................................................................................................................. 115


V TABLE OF CONTENTS

Benefits for Preventive Care Medications ............................................................................ 116

Designated Pharmacy .............................................................................................................. 116

Assigning Prescription Drugs to the PDL ........................................................................... 116

Notification Requirements ..................................................................................................... 117

Prescription Drug Benefit Claims ......................................................................................... 118

Limitation on Selection of Pharmacies ................................................................................. 118

Supply Limits ............................................................................................................................ 118

If a Brand-name Drug Becomes Available as a Generic .................................................... 118

Special Programs ...................................................................................................................... 119

Prescription Drug Products Prescribed by a Specialist Physician .................................... 119

Step Therapy ............................................................................................................................. 119

Rebates and Other Discounts ................................................................................................ 119

Coupons, Incentives and Other Communications ............................................................. 119

Exclusions - What the Prescription Drug Plan Will Not Cover ....................................... 120

Glossary - Prescription Drugs ................................................................................................ 122

SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION ............................................... 126

ATTACHMENT I - HEALTH CARE REFORM NOTICES ............................................................. 127 Patient Protection and Affordable Care Act ("PPACA") .................................................. 127

ATTACHMENT II - LEGAL NOTICES .......................................................................................... 128 Women's Health and Cancer Rights Act of 1998 ............................................................... 128

Statement of Rights under the Newborns' and Mothers' Health Protection Act .......... 128

ATTACHMENT III - The Use and Disclosure of Protected Health Information ....................... 129

ATTACHMENT IV – Nondiscrimination and Accessibility Requirements ............................... 131

ATTACHMENT V – GETTING HELP IN OTHER LANGUAGES OR FORMATS ......................... 133

ADDENDUM - UNITEDHEALTH ALLIES ..................................................................................... 140 Introduction .............................................................................................................................. 140

What is UnitedHealth Allies? ................................................................................................. 140

Selecting a Discounted Product or Service .......................................................................... 140

Visiting Your Selected Health Care Professional ................................................................ 140

Additional UnitedHealth Allies Information ....................................................................... 141


VI TABLE OF CONTENTS

ADDENDUM - PARENTSTEPS® .................................................................................................. 142 Introduction .............................................................................................................................. 142

What is ParentSteps? ............................................................................................................... 142

Registering for ParentSteps .................................................................................................... 142

Selecting a Contracted Provider............................................................................................. 142

Visiting Your Selected Health Care Professional ................................................................ 143

Obtaining a Discount .............................................................................................................. 143

Speaking with a Nurse ............................................................................................................. 143

Additional ParentSteps Information ..................................................................................... 143


1 SECTION 1 - WELCOME

SECTION 1 - WELCOME

Quick Reference Box ■ Member services, claim inquiries, Personal Health Support and Mental

Health/Substance Use Disorder Administrator: 1-877-644-9382;

■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, Utah 84130-0555; and

■ Online assistance: www.myuhc.com.

Waukesha County is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members. It includes summaries of:

■ who is eligible;

■ services that are covered, called Covered Health Services;

■ services that are not covered, called Exclusions;

■ how Benefits are paid; and

■ your rights and responsibilities under the Plan.

This SPD is designed to meet your information needs. It supersedes any previous printed or electronic SPD for this Plan.

Waukesha County intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.

UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Waukesha County is solely responsible for paying Benefits described in this SPD.

Please read this SPD thoroughly to learn how the Plan works. If you have questions contact your local Human Resources department or call the number on the back of your ID card.


2 SECTION 1 - WELCOME

How To Use This SPD ■ Read the entire SPD, and share it with your family. Then keep it in a safe place for

future reference.

■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

■ You can find copies of your SPD and any future amendments or request printed copies by contacting Human Resources.

■ Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.

■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.

■ Waukesha County is also referred to as Company.

■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.


3 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes: ■ Who's eligible for coverage under the Plan;

■ The factors that impact your cost for coverage;

■ Instructions and timeframes for enrolling yourself and your eligible Dependents;

■ When coverage begins; and

■ When you can make coverage changes under the Plan.

Eligibility You are eligible to enroll in the Plan if you are a former regular full-time employee or a retiree of the Plan Sponsor who was scheduled to work at his or her job at least 40 hours per week or a former regular part-time employee scheduled to work at least 20 hours per week, who retires while covered under the Plan and is not eligible for Medicare.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

■ your Spouse, as defined in Section 14, Glossary;

■ your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian;

■ the child of your eligible Dependent child who is under the age of 18 until the end of the month in which the child of your eligible Dependent child attains the limiting age; or

■ an unmarried child age 26 or over who is or becomes disabled and dependent upon you.

To be eligible for coverage under the Plan, a Dependent must reside within the United States.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

Cost of Coverage You and Waukesha County share in the cost of the Plan. Your contribution amount depends on the Plan you select and the family members you choose to enroll.

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.



Your contributions are subject to review and Waukesha County reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling Human Resources.

How to Enroll To enroll, call Human Resources within 31 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 31 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Open Enrollment will become effective the following January 1.

Important If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact Human Resources within 31 days of the event. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins Coverage begins immediately upon retirement if the Plan Administrator receives the properly completed enrollment form and any required contribution for coverage within 60 days of the date the new Eligible Person becomes eligible to enroll and if the Participant pays any required contribution to the Plan Administrator for Coverage.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the date of your marriage, provided you notify Human Resources within 31 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided you notify Human Resources within 31 days of the birth, adoption, or placement.

If You Are Hospitalized When Your Coverage Begins If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as soon as is reasonably possible. Network Benefits are available only if you receive Covered Health Services from Network providers.

Changing Your Coverage You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover



your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

■ your marriage, divorce, legal separation or annulment;

■ the birth, adoption, placement for adoption or legal guardianship of a child;

■ a change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan;

■ loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis;

■ the death of a Dependent;

■ your Dependent child no longer qualifying as an eligible Dependent;

■ a change in your or your Spouse's position or work schedule that impacts eligibility for health coverage;

■ contributions were no longer paid by the employer (This is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer);

■ you or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent;

■ benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent;

■ termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact Human Resources within 60 days of termination);

■ you or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact Human Resources within 60 days of determination of subsidy eligibility);

■ a strike or lockout involving you or your Spouse; or

■ a court or administrative order.

Unless otherwise noted above, if you wish to change your elections, you must contact Human Resources within 31 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.



Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

Change in Family Status - Example Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in Waukesha County's medical plan, because her husband, Tom, has family coverage under his employer's medical plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical coverage. Due to this family status change, Jane can elect family medical coverage under Waukesha County's medical plan outside of annual Open Enrollment.


7 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes: ■ Accessing Network and Non-Network Benefits;

■ Eligible Expenses;

■ Annual Deductible;

■ Coinsurance; and

■ Out-of-Pocket Maximum.

Accessing Network and Non-Network Benefits As a participant in this Plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare to provide those services.

You can choose to receive Network Benefits or Non-Network Benefits.

Network Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. Emergency Health Services are always paid as Network Benefits. For facility charges, these are Benefits for Covered Health Services that are billed by a Network facility and provided under the direction of either a Network or non-Network Physician or other provider. Network Benefits include Physician services provided in a Network facility by a Network or a non-Network radiologist, anesthesiologist, pathologist and Emergency room Physician.

Non-Network Benefits apply to Covered Health Services that are provided by a non-Network Physician or other non-Network provider, or Covered Health Services that are provided at a non-Network facility.

Depending on the geographic area and the service you receive, you may have access through UnitedHealthcare's Shared Savings Program to non-Network providers who have agreed to discounts negotiated from their charges on certain claims for Covered Health Services. Refer to the definition of Shared Savings Program in Section 14, Glossary, of the SPD for details about how the Shared Savings Program applies.

You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive.



Generally, when you receive Covered Health Services from a Network provider, you pay less than you would if you receive the same care from a non-Network provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network provider.

If you choose to seek care outside the Network, the Plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum. You may want to ask the non-Network provider about their billed charges before you receive care.

Health Services from Non-Network Providers Paid as Network Benefits If specific Covered Health Services are not available from a Network provider, you may be eligible to receive Network Benefits from a non-Network provider. In this situation, your Network Physician will notify the Claims Administrator and if the Claims Administrator confirms that care is not available from a Network provider, the Claims Administrator will work with you and your Network Physician to coordinate care through a non-Network provider.

When you receive Covered Health Services through a Network Physician, the Plan will pay Network Benefits for those Covered Health Services, even if one or more of those Covered Health Services is received from a non-Network provider.

Looking for a Network Provider? In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

Network Providers UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of Network providers free of charge. Keep in mind, a provider's Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the toll-free number on your ID card or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of Waukesha County or UnitedHealthcare.

UnitedHealthcare’s credentialing process confirms public information about the providers’ licenses and other credentials, but does not assure the quality of the services provided.

Possible Limitations on Provider Use If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to coordinate all of your future Covered Health Services. If you don't make a selection within 31 days of the date you are notified, UnitedHealthcare will select a Network Physician for you. In the event that you



do not use the Network Physician to coordinate all of your care, any Covered Health Services you receive will be paid at the non-Network level.

Eligible Expenses Waukesha County has delegated to the Claims Administrator the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Eligible Expenses are the amount the Claims Administrator determines that the Claims Administrator will pay for Benefits. For Network Benefits, you are not responsible for any difference between Eligible Expenses and the amount the provider bills. For Network Benefits for Covered Health Services provided by a non-Network provider (other than Emergency Health Services or services otherwise arranged by UnitedHealthcare), you will be responsible to the non-Network Physician or provider for any amount billed that is greater than the amount UnitedHealthcare determines to be an Eligible Expense as described below. For Non-Network Benefits, you are responsible for paying, directly to the non-Network provider, any difference between the amount the provider bills you and the amount the Claims Administrator will pay for Eligible Expenses. Eligible Expenses are determined solely in accordance with the Claims Administrator's reimbursement policy guidelines, as described in the SPD.

For Network Benefits, Eligible Expenses are based on the following:

■ When Covered Health Services are received from a Network provider, Eligible Expenses are the Claims Administrator's contracted fee(s) with that provider.

■ When Covered Health Services are received from a non-Network provider as a result of an Emergency or as arranged by UnitedHealthcare, Eligible Expenses are an amount negotiated by UnitedHealthcare or an amount permitted by law.

For Non-Network Benefits, Eligible Expenses are based on either of the following:

■ When Covered Health Services are received from a non-Network provider, Eligible Expenses are determined, based on:

- Negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of the Claims Administrator's vendors, affiliates or subcontractors, at the Claims Administrator's discretion.

- If rates have not been negotiated, then one of the following amounts:

♦ For Covered Health Services other than Pharmaceutical Products, Eligible Expenses are determined based on available data resources of competitive fees in that geographic area.

♦ For Mental Health Services and Substance Use Disorder Services the Eligible Expense will be reduced by 25% for Covered Health Services provided by a psychologist and by 35% for Covered Health Services provided by a masters level counselor.



♦ When Covered Health Services are Pharmaceutical Products, Eligible Expenses are determined based on 110% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market. When a rate is not published by CMS for the service, the Claims Administrator uses a gap methodology established by OptumInsight and/or a third party vendor that uses a relative value scale. The relative value scale is usually based on the difficulty, time, work, risk and resources of the service. If the relative value scale currently in use becomes no longer available, the Claims Administrator will use a comparable scale(s). UnitedHealthcare and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to UnitedHealthcare's website at www.myuhc.com for information regarding the vendor that provides the applicable gap fill relative value scale information.

IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider's billed charges and the Eligible Expense described here.

■ When Covered Health Services are received from a Network provider, Eligible Expenses are the Claims Administrator's contracted fee(s) with that provider.

Don't Forget Your ID Card Remember to show your UnitedHealthcare ID card every time you receive health care services from a provider. If you do not show your ID card, a provider has no way of knowing that you are enrolled under the Plan.

Annual Deductible The Annual Deductible is the amount of Eligible Expenses you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits. There are separate Network and non-Network Annual Deductibles for this Plan. The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

When a Covered Person was previously covered under a benefit plan that was replaced by the Plan, any amount already applied to that annual deductible provision of the prior plan will apply to the Annual Deductible provision under this Plan.

Coinsurance Coinsurance is the percentage of Eligible Expenses that you are responsible for paying. Coinsurance is a fixed percentage that applies to certain Covered Health Services after you meet the Annual Deductible.



Out-of-Pocket Maximum The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. There are separate Network and non-Network Out-of-Pocket Maximums for this Plan. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.

The following table identifies what does and does not apply toward your Network and non-Network Out-of-Pocket Maximums:

Plan Features Applies to the

Network Out-of-Pocket Maximum?

Applies to the Non-Network Out-of-Pocket

Maximum?

Copays, even those for Covered Health Services available in Section 15, Prescription Drugs

Yes Yes

Payments toward the Annual Deductible No No

Coinsurance Payments, even those for Covered Health Services available in Section 15, Prescription Drugs

Yes Yes

Charges for non-Covered Health Services No No

The amounts of any reductions in Benefits you incur by not notifying Personal Health Support

No No

Charges that exceed Eligible Expenses No No


12 SECTION 4 - PERSONAL HEALTH SUPPORT

SECTION 4 - PERSONAL HEALTH SUPPORT

What this section includes: ■ An overview of the Personal Health Support program; and

■ Covered Health Services for which you need to contact Personal Health Support.

UnitedHealthcare provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available. A Personal Health Support nurse is notified when you or your provider calls the toll-free number on your ID card regarding an upcoming treatment or service.

Personal Health Support nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. As of the publication of this SPD, the Personal Health Support program includes:

■ Admission counseling - Nurse Advocates are available to help you prepare for a successful surgical admission and recovery. Call the number on the back of your ID card for support.

■ Inpatient care management - If you are hospitalized, a Personal Health Support nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

■ Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

■ Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support nurse to discuss and share important health care information related to the participant's specific chronic or complex condition.

If you do not receive a call from a Personal Health Support nurse but feel you could benefit from any of these programs, please call the toll-free number on your ID card.



Prior Authorization UnitedHealthcare requires prior authorization for certain Covered Health Services. In general, Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization. However, if you choose to receive Covered Health Services from a non-Network provider, you are responsible for obtaining prior authorization before you receive the services. There are some Network Benefits, however, for which you are responsible for obtaining authorization before you receive the services. Services for which prior authorization is required are identified below and in Section 6, Additional Coverage Details within each Covered Health Service category.

It is recommended that you confirm with the Claims Administrator that all Covered Health Services listed below have been prior authorized as required. Before receiving these services from a Network provider, you may want to contact the Claims Administrator to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize as required. You can contact the Claims Administrator by calling the number on the back of your ID card.

When you choose to receive certain Covered Health Services from non-Network providers, you are responsible for obtaining prior authorization before you receive these services. Note that your obligation to obtain prior authorization is also applicable when a non-Network provider intends to admit you to a Network facility or refers you to other Network providers.

To obtain prior authorization, call the number on the back of your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs.

Covered Health Services which Require Prior Authorization Network providers are generally responsible for obtaining prior authorization from the Claims Administrator or contacting Personal Health Support before they provide certain services to you. However, there are some Network Benefits for which you are responsible for obtaining prior authorization from the Claims Administrator.

When you choose to receive certain Covered Health Services from non-Network providers, you are responsible for obtaining prior authorization from the Claims Administrator before you receive these Covered Health Services. In many cases, your Non-Network Benefits will be reduced if the Claims Administrator has not provided prior authorization.



Services for which you are required to obtain prior authorization are identified in Section 6, Additional Coverage Details, within each Covered Health Service Benefit description. Please note that prior authorization timelines apply. Refer to the applicable Benefit description to determine how far in advance you must provide prior authorization and any applicable reductions in Benefits.

Please note that prior authorization is required even if you have a referral from your Primary Physician to seek care from another Network Physician.

Prior authorization is required within 48 hours of admission or on the same day of admission if reasonably possible after you are admitted to a non-Network Hospital as a result of an Emergency.

For prior authorization timeframes and any reductions in Benefits that apply if you do not obtain prior authorization from the Claims Administrator or contact Personal Health Support, see Section 6, Additional Coverage Details.

Contacting the Claims Administrator or Personal Health Support is easy. Simply call the toll-free number on your ID card.

Special Note Regarding Medicare If you are enrolled in Medicare on a primary basis and Medicare pays benefits before the Plan, you are not required to notify Personal Health Support before receiving Covered Health Services. Since Medicare pays benefits first, the Plan will pay Benefits second as described in Section 10, Coordination of Benefits (COB).


15 SECTION 5 - PLAN HIGHLIGHTS

SECTION 5 - PLAN HIGHLIGHTS

The table below provides an overview of the Plan's Annual Deductible and Out-of-Pocket Maximum.

Plan Features Network Non-Network

Annual Deductible1

■ Individual $750 $1,500 ■ Family (not to exceed the applicable

Individual amount per Covered Person)

$2,250 $4,500

Annual Out-of-Pocket Maximum1,2

■ Individual $2,000 $4,000 ■ Family (not to exceed the applicable

Individual amount per Covered Person)

$4,000 $8,000

Lifetime Maximum Benefit3 There is no dollar limit to the amount the Plan will pay for essential Benefits during the entire period you are enrolled in this Plan.

Unlimited

1The Annual Deductible does not apply toward the Out-of-Pocket Maximum for any Covered Health Services.

2The Out-of-Pocket Maximum does not apply toward the following Covered Health Services. • Vision Services

• Mental Health/Chemical Dependency

• Pharmacy

3Generally the following are considered to be essential benefits under the Patient Protection and Affordable Care Act: Ambulatory patient services; emergency services, hospitalization; maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. This table provides an overview of the Plan's coverage levels. For detailed descriptions of your Benefits, refer to Section 6, Additional Coverage Details.



Covered Health Services1 Percentage of Eligible Expenses

Payable by the Plan:

Network Non-Network

Ambulance Services - Emergency Only Ground and/or Air Transportation

70% after you meet the Annual Deductible

Ground and/or Air Transportation

70% after you meet the Network

Annual Deductible

Autism Spectrum Disorder Services

Benefits will be the same as those stated under each Covered Health Service

category in this section.

Cancer Resource Services (CRS)2

■ Hospital - Inpatient Stay


Not Covered

Congenital Heart Disease (CHD) Surgeries

See Section 6, Additional Coverage Details, for limits



Dental Services - Accident Only




Diabetes Treatment




Durable Medical Equipment (DME) See Section 6, Additional Coverage Details for limits.



Emergency Health Services - Outpatient


70% after you meet the Network

Annual Deductible





Network Non-Network

Eye Examinations




Foot Care




Hearing Aids See Section 6, Additional Coverage Details, for limits



Home Health Care See Section 6, Additional Coverage Details, for limits



Hospice Care See Section 6, Additional Coverage Details, for limits



Hospital - Inpatient Stay 70% after you meet the Annual Deductible


Infertility Services See Section 6, Additional Coverage Details, for limits.


Not Covered

Injections received in a Physician's Office

70% per injection after you meet the Annual Deductible

50% per injection after you meet the Annual Deductible

Kidney Disease Treatment 70% after you meet the Annual Deductible


Kidney Resource Services (KRS) (These Benefits are for Covered Health Services provided through KRS only)


Not Covered





Network Non-Network

Maternity Services Benefits will be the same as those stated under each Covered Health Service


A Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.

Mental Health Services




■ Physician's Office Services - Outpatient



Neurobiological Disorders - Autism Spectrum Disorder Services







Ostomy Supplies See Section 6, Additional Coverage Details for limits



Outpatient Surgery, Diagnostic and Therapeutic Services

■ Outpatient Surgery







Network Non-Network ■ Outpatient Diagnostic Services

- Lab and radiology/X-ray



- Mammography testing



- Sickness and Injury related diagnostic services



■ Outpatient Diagnostic/Therapeutic Services - CT Scans, PET Scans, MRI and Nuclear Medicine



■ Outpatient Therapeutic Treatments



Physician Fees for Surgical and Medical Services



Physician's Office Services 70% after you meet the Annual Deductible


Preventive Care Services

■ Physician Office Services 70% after you meet the Annual Deductible


■ Outpatient Diagnostic Services 70% after you meet the Annual Deductible


■ Breast Pumps Not Covered Not Covered





Network Non-Network

Prosthetic Devices See Section 6, Additional Coverage Details, for limits



Reconstructive Procedures Benefits will be the same as those stated under each Covered Health Service


Rehabilitation Services - Outpatient See Section 6, Additional Coverage Details, for limits



Skilled Nursing Facility/Inpatient Rehabilitation Facility Services See Section 6, Additional Coverage Details, for limits


If you are transferred to a Skilled Nursing Facility or Inpatient

Rehabilitation Facility directly from an acute facility, any

combination of Copayments required for the Inpatient Stay in a Hospital and the

Inpatient Stay in a Skilled Nursing

Facility or Inpatient Rehabilitation

Facility will apply to the stated maximum

Copayment per Inpatient Stay.


Spinal Treatment See Section 6, Additional Coverage Details, for limits







Network Non-Network

Substance Use Disorder Services







Temporomandibular Joint Dysfunction (TMJ)


Benefits will be the same as those stated under each Covered Health Service


Transitional Care Services for Mental Health Services See Section 6, Additional Coverage Details, for limits



Transplantation Services Depending upon where the Covered Health Services is provided, Benefits for

transplantation services will be the same as those stated under each Covered Health

Services category in this section.

Travel and Lodging

(If services rendered by a Designated Provider)

For patient and companion(s) of patient undergoing transplant procedures

Urgent Care Center Services 70% after you meet the Annual Deductible


Wisdom Teeth See Section 6, Additional Coverage Details, for limits







Network Non-Network

1You must notify Personal Health Support, as described in Section 4, Personal Health Support to receive full Benefits before receiving certain Covered Health Services from a non-Network provider. In general, if you visit a Network provider, that provider is responsible for notifying Personal Health Support before you receive certain Covered Health Services. See Section 6, Additional Coverage Details for further information.

2These Benefits are for Covered Health Services provided through CRS at a Designated Provider. For oncology services not provided through CRS, the Plan pays Benefits as described under Physician's Office Services - Sickness and Injury, Physician Fees for Surgical and Medical Services, Hospital - Inpatient Stay, Surgery - Outpatient, Scopic Procedures - Outpatient Diagnostic and Therapeutic Lab, X-Ray and Diagnostics – Outpatient, and Lab, X-Ray and Major Diagnostics – CT, PET, MRI, MRA and Nuclear Medicine – Outpatient.


23 SECTION 6 - ADDITIONAL COVERAGE DETAILS

SECTION 6 - ADDITIONAL COVERAGE DETAILS

What this section includes: ■ Covered Health Services for which the Plan pays Benefits; and

■ Covered Health Services that require you to obtain prior authorization before you receive them, and any reduction in Benefits that may apply if you do not call to obtain prior authorization.

This section supplements the second table in Section 5, Plan Highlights.

While the table provides you with Benefit limitations along with Copayment, Coinsurance and Annual Deductible information for each Covered Health Service, this section includes descriptions of the Benefits. These descriptions include any additional limitations that may apply, as well as Covered Health Services for which you must obtain prior authorization from the Claims Administrator as required. The Covered Health Services in this section appear in the same order as they do in the table for easy reference. Services that are not covered are described in Section 8, Exclusions and Limitations.

Ambulance Services - Emergency only Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency health services can be performed.

Prior Authorization Requirement In most cases, the Claims Administrator will initiate and direct non-Emergency ambulance transportation. If you are requesting non-Emergency ambulance services, please remember that you must obtain prior authorization as soon as possible prior to transport. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses, however the reduction of benefits will not exceed $500.

Autism Spectrum Disorder Services The following definitions apply for purposes of Autism Spectrum Disorders:

"Autism Spectrum Disorders" means any of the following:

■ Autism disorder.

■ Asperger's Syndrome.

■ Pervasive development disorder not otherwise specified.

"Intensive-level services" means evidence-based behavioral therapies that are designed to help an individual with autism spectrum disorder overcome the cognitive, social and behavioral deficits associated with that disorder.

"Non-intensive-level services" means evidence-based therapy that occurs after the completion of treatment for Intensive-level services or, for an individual who has not and



will not receive intensive-level services, evidence-based therapy that will improve the individual's condition.

Intensive Level Services Note: Benefits for intensive-level services begin after the Enrolled Dependent child turns two years of age but prior to turning nine years of age.

Benefits are provided for evidence-based behavioral intensive-level therapy for an insured with a verified diagnosis of autism spectrum disorder, the majority of which shall be provided to the Enrolled Dependent child when the parent or legal guardian is present and engaged. The prescribed therapy must be consistent with all of the following requirements:

■ Based upon a treatment plan developed by a qualified provider that includes at least 20 hours per week over a six-month period of time of evidence-based behavioral intensive therapy, treatment and services with specific cognitive, social, communicative, self-care, or behavioral goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the Enrolled Dependent child be present and engaged in the intervention.

■ Implemented by qualified providers, qualified supervising provider, qualified professional, qualified therapists or qualified paraprofessionals.

■ Provided in an environment most conducive to achieving the goals of the Enrolled Dependent child's treatment plan.

■ Included training and consultation, participation in team meeting and active involvement of the Enrolled Dependent child's family and treatment team for implementation of the therapeutic goals developed by the team.

■ The Enrolled Dependent child is directly observed by the qualified provider at least once every two months.

■ Beginning after the Enrolled Dependent child is two years of age and before the Enrolled Dependent child is nine years of age.

Intensive-level services will be covered for up to four cumulative years. We may credit against any previous intensive-level services the Enrolled Dependent child received against the required four years of intensive-level services regardless of payer. We may also require documentation including medical records and treatment plans to verify any evidence-based behavioral therapy the insured received for autism spectrum disorders that was provided to the Enrolled Dependent child prior to attaining nine years of age. Evidence-based behavioral therapy that was provided to the Enrolled Dependent child for an average of 20 or more hours per week over a continuous six-month period to be intensive-level services.

Travel time for qualified providers, supervising providers, professionals, therapists or paraprofessionals is not included when calculating the number of hours of care provided per week. We are not required to reimburse for travel time.

We require that progress be assessed and documented throughout the course of treatment. We may request and review the Enrolled Dependent child's treatment plan and the summary of progress on a periodic basis.



Non-Intensive Level Services Non-intensive Level Services will be covered for an Enrolled Dependent child with a verified diagnosis of autism spectrum disorder for non-intensive level services that are evidence-based and are provided to an Enrolled Dependent child by a qualified provider, professional, therapist or paraprofessional in either of the following conditions:

■ After the completion of intensive-level services and designed to sustain and maximize gains made during intensive level services treatment.

■ To an Enrolled Dependent child who has not and will not receive intensive-level services but for whom non-intensive level services will improve the Enrolled Dependent child's condition.

Benefits will be provided for evidence-based therapy that is consistent with all of the following requirements:

■ Based upon a treatment plan developed by a qualified provider, supervising provider, professional or therapist that includes specific therapy goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the Enrolled Dependent child be present and engaged in the intervention.

■ Implemented by qualified providers, qualified supervising providers, qualified professionals, qualified therapist or qualified paraprofessionals.

■ Provided in an environment most conducive to achieving the goal of the Enrolled Dependent child's treatment plan.

■ Included training and consultation, participation in team meetings and active involvement of the Enrolled Dependent child's family in order to implement the therapeutic goals developed by the team.

■ Provided supervision of providers, professionals, therapists and paraprofessionals by qualified supervising providers on the treatment team.

Non-intensive level services may include direct or consultative services when provided by qualified providers, qualified supervising providers, qualified professionals, qualified paraprofessionals, or qualified therapists.

We require that progress be assessed and documented throughout the course of treatment. We may request and review the Enrolled Dependent child's treatment plan and the summary of progress on a periodic basis.

Travel time for qualified providers, qualified supervising providers, qualified professional, qualified therapists or qualified paraprofessionals in not included when calculating the number of hours of care provided per week. We are not required to reimburse for travel time.

Intensive-level and Non-intensive-level services include but are not limited to speech, occupational and behavioral therapies.



Prior Authorization Requirement Depending upon where the Covered Health Service is provided, any applicable notification or authorization requirements will be the same as those stated under each Covered Health Service category.

Cancer Resource Services (CRS) The Plan pays Benefits for oncology services provided by Designated Provider participating in the Cancer Resource Services (CRS) program. Designated Provider is defined in Section 14, Glossary.

For oncology services and supplies to be considered Covered Health Services, they must be provided to treat a condition that has a primary or suspected diagnosis relating to cancer. If you or a covered Dependent has cancer, you may:

■ be referred to CRS by Personal Health Support;

■ call CRS toll-free at (866) 936-6002; or

■ visit www.myoptumhealthcomplexmedical.com.

To receive Benefits for a cancer-related treatment, you are not required to visit a Designated Provider. If you receive oncology services from a facility that is not a Designated Provider, the Plan pays Benefits as described under:

■ Physician's Office Services - Sickness and Injury;

■ Physician Fees for Surgical and Medical Services;

■ Outpatient Surgery, Diagnostic and Therapeutic Services;

■ Therapeutic Treatments - Outpatient;

■ Hospital - Inpatient Stay; and

■ Surgery - Outpatient.

To receive Benefits under the CRS program, you must contact CRS prior to obtaining Covered Health Services. The Plan will only pay Benefits under the CRS program if CRS provides the proper notification to the Designated Provider performing the services (even if you self-refer to a provider in that Network).

Congenital Heart Disease (CHD) Surgeries The Plan pays Benefits for Congenital Heart Disease (CHD) services ordered by a Physician and received at a CHD Resource Services program. Benefits include the facility charge and the charge for supplies and equipment. Benefits are available for the following CHD services:

■ outpatient diagnostic testing;

■ evaluation;



■ surgical interventions;

■ interventional cardiac catheterizations (insertion of a tubular device in the heart);

■ fetal echocardiograms (examination, measurement and diagnosis of the heart using ultrasound technology); and

■ approved fetal interventions.

CHD services other than those listed above are excluded from coverage, unless determined by United Resource Networks or Personal Health Support to be proven procedures for the involved diagnoses. Contact United Resource Networks at (888) 936-7246 or Personal Health Support at the toll-free number on your ID card for information about CHD services.

If you receive Congenital Heart Disease services from a facility that is not a Designated Provider, the Plan pays Benefits as described under:

■ Physician's Office Services - Sickness and Injury;

■ Physician Fees for Surgical and Medical Services;

■ Outpatient Surgery, Diagnostic and Therapeutic Services;

■ Therapeutic Treatments - Outpatient;

■ Hospital - Inpatient Stay; and

■ Surgery - Outpatient.

Prior Authorization Requirement For Non-Network Benefits you must obtain prior authorization from the Claims Administrator as soon as the possibility of a CHD surgery arises. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses

Dental Services - Accident Only Dental services when all of the following are true:

■ treatment is necessary because of accidental damage;

■ dental services are received from a Doctor of Dental Surgery, "D.D.S." or Doctor of Medical Dentistry, "D.M.D.";

■ the dental damage is severe enough that initial contact with a Physician or dentist occurred within 72 hours of the accident.

Benefits are available only for treatment of a sound, natural tooth. The Physician or dentist must certify that the injured tooth was:

■ a virgin or unrestored tooth; or



■ a tooth that has no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant and functions normally in chewing and speech.

Hospital or ambulatory surgery center charges provided in conjunction with dental care, including anesthetics provided are covered, if any of the following applies. The Covered Person:

■ Is a child under the age of 5

■ Has a chronic disability

■ Has a medical condition requiring hospitalization of general anesthesia for dental care

Dental services for final treatment to repair the damage must be both of the following:

■ Started within three months of the accident, or if not a Covered Person at the time of the accident, within the first three months of coverage under the Plan.

■ Completed within 12 months of the accident, or if not a Covered Person at the time of the accident, within the first 12 months of coverage under the Plan.

Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of the teeth is not considered an "accident". Benefits are not available for repairs to teeth that are injured as a result of such activities.

Please remember that you must obtain prior authorization from the Claims Administrator as soon as possible, but at least five business days before follow-up (post-Emergency) treatment begins. You do not have to obtain prior authorization before the initial Emergency treatment. When you obtain prior authorization, the Claims Administrator, can determine whether the service is a Covered Health Service. If prior authorization is not obtained, Benefits will be reduced to 50% of Eligible Expenses; however, the reduction of benefits will not exceed $500.

Diabetes Treatment Supplies and equipment for the treatment of diabetes including one insulin infusion pump per calendar year.

Durable Medical Equipment (DME) The Plan pays for Durable Medical Equipment (DME) that meets each of the following:

■ ordered or provided by a Physician for outpatient use;

■ used for medical purposes;

■ not consumable or disposable; and

■ not of use to a person in the absence of a disease or disability.



If more than one piece of DME can meet your functional needs, Benefits are available only for the most Cost-Effective piece of equipment.

Examples of DME include but are not limited to:

■ equipment to assist mobility, such as a standard wheelchair;

■ a standard Hospital-type bed;

■ oxygen concentrator units and the rental of equipment to administer oxygen;

■ delivery pumps for tube feedings;

■ braces, including necessary adjustments to shoes to accommodate braces. Braces that stabilize an Injured body part and braces to treat curvature of the spine are considered Durable Medical Equipment and are a Covered Health Service. Braces that straighten or change the shape of a body part are orthotic devices, and are excluded from coverage. Dental braces are also excluded from coverage.

■ mechanical equipment necessary for the treatment of chronic or acute respiratory failure (except that air-conditioners, humidifiers, dehumidifiers, air purifiers and filters, and personal comfort items are excluded from coverage).

UnitedHealthcare provides Benefits only for a single purchase (including repair/ replacement) of a type of Durable Medical Equipment once every three calendar years.

Prior Authorization Requirement For Non-Network Benefits you must obtain prior authorization from the Claims Administrator before obtaining any Durable Medical Equipment that exceeds $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a single item). If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses, however the reduction of benefits will not exceed $500.

Emergency Health Services - Outpatient The Plan pays for services that are required to stabilize or initiate treatment in an Emergency. Emergency health services must be received on an outpatient basis at a Hospital or Alternate Facility.

Network Benefits will be paid for an Emergency admission to a non-Network Hospital as long as Personal Health Support is notified within two business days of the admission or on the same day of admission if reasonably possible after you are admitted to a non-Network Hospital. If you continue your stay in a non-Network Hospital after the date your Physician determines that it is medically appropriate to transfer you to a Network Hospital, Non-Network Benefits will apply.

Benefits under this section are not available for services to treat a condition that does not meet the definition of an Emergency.



Eye Examinations The Plan pays Benefits for eye examinations received from a health care provider in the provider's office as part of the treatment of a disease or injury.

Benefits do not include routine vision exams.

Please note that Benefits are not available for charges connected to the purchase or fitting of eyeglasses or contact lenses.

Foot Care Non-routine foot care provided by a Network Podiatrist.

Hearing Aids The Plan pays Benefits for hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver.

Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a Physician. Benefits are provided for the hearing aid and for charges for associated fitting and testing.

Benefits do not include bone anchored hearing aids. Bone anchored hearing aids are a Covered Health Service for which Benefits are available under the applicable medical/surgical Covered Health Services categories in this section only for Covered Persons who have either of the following:

■ craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid; or

■ hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.

Benefits are limited to a single purchase (including repair/replacement) per hearing impaired ear every three calendar years.

Home Health Care Covered Health Services are services received from a Home Health Agency that are both of the following:

■ ordered by a Physician; and

■ provided by or supervised by a registered nurse in your home.

Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when skilled home health care is required.



Skilled home health care is skilled nursing, skilled teaching, and skilled rehabilitation services when all of the following are true:

■ it must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient;

■ it is ordered by a Physician;

■ it is not delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from a bed to a chair;

■ it requires clinical training in order to be delivered safely and effectively; and

■ it is not Custodial Care.

Any combination of Network Benefits and Non-Network Benefits is limited to 40 visits per calendar year. One visit equals four hours of Skilled Care services. Intravenous Infusion Services and Therapies are not subject to the calendar year maximum.

Prior Authorization Requirement For Non-Network Benefits you must obtain prior authorization from the Claims Administrator five business days before receiving services or as soon as is reasonably possible. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses, howeve

Documents

Waukesha County Choice Plus Retiree Health Plan with ...€¦ · 01/01/2018 · Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, Utah 84130-0555;